That Good Night
Page 4
I moved through the rest of my day, seeing my other patients and discussing my care plan for each one with the two physicians supervising and teaching me: Andrew, a second-year resident, and Dr. Michaels, an attending physician who had finished his residency ten years earlier. As the late- afternoon sky darkened into night, I sat in the residents’ room on the ninth floor of the hospital, writing the ten patient notes I had to complete before going home. The room was a workspace lined with computers and lockers for my fellow residents and me. Battered couches surrounded a table littered with half-eaten bags of chips, crumbs from a grease-stained pink box of muffins, and takeout menus from nearby Chinese and Indian fast-food restaurants. This was where we alternately shared the details of challenging cases and bemoaned the inconveniences of residency. During overnight calls, we huddled together in this room, sharing late-night ice cream bars from the cafeteria and draping warm blankets from the ICU over our shoulders as we typed our notes or researched the treatment of unusual diseases. Though the residents’ room was often cluttered and smelled of a strange combination of coffee and sweat, it boasted a view that consistently brought me peace.
From this windowed room, I could catch the first glimpse of the evening fog’s gray fingers stretching forth from the San Francisco Bay, grasping the city in its embrace. During overnight calls spent seeing and admitting new patients to the hospital, I wrote my patient notes in this same room, pausing to watch the sun spill slowly across the city like liquid gold against the rust and pink of the day’s earliest sky.
Between my four years in medical school, two years doing research, and the start of my residency, I had been living in the Bay Area for nearly seven years. But I’d never found a view of San Francisco as incredible as the one from inside the walls of this hospital. From a conference room on the fourteenth floor, I took in the reliability of the sunrise and sunset over the city’s bridges, hills, and vast patches of greenery, which contrasted sharply with the controlled but unpredictable atmosphere of the hospital. I meandered up to this room most mornings to take in the view before rounds. I pressed my palm against the cool window, its pane bejeweled with the day’s earliest dew. I pressed my palm against this window now, as I took a break from note writing, wishing I could reach through to the wisps of scattered clouds, a mess of stars emerging around them. This window, the thin barrier between the order of nature and the chaos of the hospital.
* * *
I wasn’t on call that day, which meant that I arrived at the hospital at 6:30 a.m. and would leave around 6:30 p.m., taking a university-operated shuttle bus back to my small apartment. Every four nights, when I was on call, I worked a thirty-hour shift to care for my list of current patients and admit new patients to the hospital. I lived in student housing near the Giants’ baseball stadium and Caltrain depot in the Mission Bay neighborhood of San Francisco. During my ride home, I turned my full attention to the scenery of San Francisco as we passed the green edges of Golden Gate Park, streets in the Tenderloin lined with hotels and clusters of homeless people outside narrow cafés, and a lonely concrete stretch of Seventh Street, where speeding cars on Interstate 280 rumbled on the freeway overpass that hovered over a set of railroad tracks.
Everything about my apartment reflected my harried life. My refrigerator was largely empty save for a few cans of Diet Coke; in one cupboard, I’d gathered a few bruised bananas and apples and bags of baked chips I’d bring home from the hospital cafeteria. A cream-colored futon and an old television I’d bought from Craigslist faced each other in the small living area, where a few of my half-written essays and medical textbooks covered my old Ikea desk. I’d taped a few photographs of my parents and brother throughout the apartment; picture frames I’d bought on sale at Rite Aid sat, unopened, in a sad pile underneath my desk. I slept on a sinking mattress under a maroon and orange duvet, and the empty half of my bed was covered with novels, collections of essays, and poetry I read before sleeping and didn’t bother to return to the bookcase: Rainer Maria Rilke’s Sonnets to Orpheus, Arundhati Roy’s The God of Small Things, Joan Didion’s Slouching Towards Bethlehem. I’d discovered them in college, when I collected syllabi of English classes I longed to take but couldn’t squeeze into a class schedule dominated by prerequisites for medical school. I bought used copies of Black Boy and The Color Purple, My Own Country and Native Speaker. I underlined passages of prose and lines of poetry that stirred emotions I couldn’t name. Though I’d sold my biology and physics textbooks years ago, and long since recycled several notebooks’ worth of chemistry lectures, I continued to sleep next to books assigned in classes I never took.
I always resolved to organize my apartment on my one day off each week, but when that day rolled around, I instead spent it sleeping in and walking along the Embarcadero to the Ferry Building. I’d meander from the bookstore to a vegan doughnut stand to a small café for lunch and walk for hours, letting the sunshine, which I sorely missed at the hospital, warm me. I’d occasionally go out to dinner at tasty, affordable places—a Vietnamese café in nearby Potrero Hill, a South Indian restaurant in the Mission—with a friend or two from my residency program. We talked about the lives of our friends who weren’t in medicine, friends who were married, who lived in homes rather than student housing, and had enough vacation time and money to leave the country or enjoy a spontaneous weekend getaway.
When I began my residency, I was thirty years old. When I caught glimpses of myself in the mirrors of our hospital’s bathroom, I saw a young woman with long black hair and a newly visible strand of gray, dark eyes encircled by faint new shadows, and a narrow face with eyebrows in need of threading. I had never been married, my few relationships crushed by my hours of studying and work and my naïve expectation that those I loved would implicitly understand the physical and emotional demands of my training. By the time my mother turned thirty, she had married a man she’d known for one week, moved with him to a new country where she didn’t have a single blood relative, given birth to two children while juggling a grueling anesthesiology residency, and started to save her meager resident’s salary for a home and for the future education of her children. At thirty, I still felt like a child, floundering to find my footing in the world, troubled by the endless transience of my training: I saw patients at three different hospitals, working with an ever-changing roster of fellow residents, students, and attending physicians, adapting my work to meet the expectations of each new supervisor. Change was the one constant in my life. I longed for stability.
My mother called me almost every day, though I wasn’t always able to pick up. Tonight, she called just as I lay down in bed, and asked me how my day had been.
“It’s been busy,” I said, closing my eyes, relaxing as her voice, in lilting Hindi, washed over me. I told her about the patient whom I’d correctly diagnosed with new-onset heart failure caused by a prior course of chemotherapy, another patient whose back pain was due to newly discovered multiple myeloma. I told her about Mr. Tan, and wondered aloud whether he would ever be well enough to leave the hospital.
“He sounds very complicated,” my mother agreed. “Nowadays, people are much sicker than before. But I didn’t take care of people the way you do in internal medicine. My job is simple—intubate them and put a few IVs in and then just wait!”
She told me that she and my father were planning their yearly trip to India; they liked to travel in January or February, when the weather was tolerable. We talked about how much her home country has changed, how she could no longer imagine living in a city swollen with people, devoid of silence, its skies darkened by the haze of pollution. I could tell this caused her great pain, returning to a place she had lost. “I don’t think so much about the past or what it used to be,” she told me when I asked if returning to India caused her more sadness than joy. “It is all temporary anyway. We have it, and then it’s gone.” This is what she often said when she spoke of India, of how it had transformed into a place that she co
uld neither recognize nor consider home. But her voice swelled with longing and regret that she couldn’t disguise, and I could sense acutely everything my parents had given up for my brother and me to have the lives we did. When I thought about pursuing a career in literature or anthropology instead of medicine, she was supportive even though she and my father had always assumed I’d follow in her footsteps. But the mix of nostalgia and grief in my mother’s voice haunted me, and I would ask myself if those careers would be worth her sacrifice. I could feel the weight of what she said and left unsaid pressing upon me in a place beyond language.
After we talked, I scoured my bookshelf for a book of poetry by Agha Shahid Ali, a Kashmiri poet I first discovered in college, though I don’t remember exactly how. I found myself searching for what my mother could not articulate.
Kashmir shrinks into my mailbox,
my home a neat four by six inches.
I always loved neatness. Now I hold the half-inch
Himalayas in my hand.
This is home. And this is the closest I’ll ever be to home.
When I return, the colors won’t be so brilliant. The Jhelum’s waters so clean, so ultramarine. My love so overexposed.
And my memory will be a little out of focus, in it a giant negative, black and white, still undeveloped.
* * *
The next morning on rounds, when I spoke to Andrew and Dr. Michaels about Mr. Tan, I said aloud the words I’d practiced as I took the shuttle to work hours earlier. “I think maybe it’s time to sit down and talk with his family about . . . where this is going,” I said haltingly, struggling at first to state my recommendation clearly, then continuing boldly. “I am worried that he may get sicker quickly, and I haven’t talked with him or his family about what we should do if that happens. Should we intubate him if he has another stroke and can’t breathe on his own? Would he want CPR to keep him from dying? Does he even really know how bad his situation is? Those seem like things we should address sooner rather than later.” I couldn’t quite articulate my other motivation for the meeting: Everyone taking care of Mr. Tan knew how dire his situation was, how the next illness could take his life. Everyone knew this, except for him.
“Sure,” Dr. Michaels said, “that’s a good idea. Those are important things to clarify. For now, let’s continue his current antibiotics and antifungals, and make sure his blood counts remain stable. Let us know how the meeting goes.” I trembled anxiously. Wouldn’t Andrew or Dr. Michaels join me? Had I been doing a technical procedure on Mr. Tan—placing an IV in a large vein in his neck, or drawing fluid out of his swollen belly—Andrew would have prepared me for and overseen the entire procedure, possibly with Dr. Michaels there to supervise both of us. Procedures were both necessary and risky, but so were family meetings, as I’d seen when working with Dr. McCormick. Words and silence, like needles and catheters, could harm or help, illuminate or injure. I thought back to my time with Dr. McCormick, when he and I would review the medical facts of a patient’s situation and decide, together, what we wanted to communicate to the patient and how. We brainstormed the sorts of questions a patient or family might ask us, and considered how we might answer. We chose our words carefully, looking for that elusive balance of discussing the reality of a patient’s situation without destroying the hope they might have for their future. I considered asking Andrew to help me plan for the meeting as Dr. McCormick had, to figure out what I wanted to communicate and how, but as an intern I often felt I had to assume an air of knowledge and competence even if I had neither. Nothing was more bothersome to supervising residents than interns who couldn’t handle supposedly simple tasks like talking to a family, especially since family meetings tended to be draining and lengthy, requiring at least an hour out of an already compressed day. As I prepared for the meeting, I remembered that I had a pocket guide to family meetings that Dr. McCormick had recommended to me, complete with bullet points to help me prepare for and carry out the meeting in an organized, compassionate way. I grabbed the guide from my backpack and hunched over a desk in the residents’ room to scribble notes that I hoped would approximate the planning I’d learned to do with Dr. McCormick.
I called Mr. Tan’s wife, Laura, and daughter, Noelle, and asked them to come into the hospital for a family meeting. No, I told them, there was no emergency. Yes, he’s doing about the same, I said. What I didn’t know how to say was that his stable instability was the problem. I had to find a kind and precise way to tell them what the surgeon had told me, to figure out what to do not if, but when, the worst-case scenario manifested.
My family is all here, he wrote later that day, when they had all arrived and gathered in his room.
A petite woman wearing baggy black pants and an oversized cardigan, Laura stood no taller than the middle of my chest. Her short dark hair, parted down the middle, framed an open face with smiling eyes and simple glasses, and she wore a circular jade pendant at her throat. “I am his wife,” she said in slightly halting English.
“Yes! I am so glad you could be here,” I said, shaking her hand. Taller than me by several inches and gracefully poised with the long torso and neck of a ballerina, Noelle had long dark hair streaked with faded highlights that she had tied back in a high ponytail. A loose dark sweater obscured her slim frame. She was in her early twenties, a junior at UC Davis. Her expression, initially grave, gave way to a warm smile when I told her that her father always kept an eye on his precious UC Davis mug. Still, her tightly folded arms betrayed the tension she was feeling, as if her arms could both steady and protect her from what this vague “check-in” might be about. Noelle spoke to me in English and to her mother in Cantonese. I knew from reading Mr. Tan’s chart that Noelle accompanied him to his doctors’ appointments, often interpreting for him and Laura. I would learn later that she chose her class schedule to accommodate her father’s clinic appointments, making sure that she could travel back home to pick up her parents, listen to the doctors’ recommendations, and ensure that all the right medications were ordered, filled, and picked up at the right pharmacy.
“Don’t worry,” I told Noelle, motioning to the hospital’s Cantonese interpreter in the room. “You can just listen today. No need at all to interpret.”
“Thank you so much,” she said quietly, her expression and folded arms unchanged.
I scanned the room quickly, trying to figure out where I should stand to lead the meeting. Next to Mr. Tan’s bed? Sitting down with his family? My anxiety got the best of me, and I stood next to his bed, even though I asked his family to please take seats in the chairs I had brought into the cramped room from the nursing station. “So, um, thank you all for being here today and coming in to talk about how Mr. Tan is doing.” The Cantonese interpreter, who stood next to the family, translated and looked back at me. I glanced down at my outline, a list of points I wanted to cover in the meeting, many of which I had cribbed from Dr. McCormick’s cheat sheet.
I felt totally alone in this room with my oldest tools—words. I took a deep breath.
1. Ask the patient/family what they know about his illness.
“So, could you tell me, what is your understanding of your medical problems?” I looked first at Noelle and Laura, then shifted my gaze back to Mr. Tan. He started writing down his answer in slow, wobbly characters: My mouth is very dry.
Huh? I thought to myself. “Oh, okay. Let’s get you some gel for your mouth,” I said, as I tried to think of another way to ask my question that would encourage him to answer it more fully. Laura smeared artificial saliva onto Mr. Tan’s lips and I tried again: “What are the neurosurgeons and infectious disease doctors telling you about your fungal infection?”
As the interpreter repeated my question in Cantonese, I glanced at the next point.
2. Correct any misunderstandings they have about how sick the patient is.
On his whiteboard, Mr. Tan responded: I don’t know.
How do I begin to explain this?
“So I need to make sure you and your family understand a few things,” I started, glancing at my notepad: Fungal infection → another stroke at some point → no surgical option, only IV antifungal medication.
3. Share information in clear, simple language.
“Unfortunately, we can only treat the fungal infection you have by giving you the medications we are already giving you through your IV,” I began. “But those medications will not cure or take away the fungus. In the best-case scenario, the medications will only prevent it from growing more. In the worst-case scenario, the infection will continue to grow even though we are giving you the IV medications. The neurosurgeon who operated on you thinks that the fungus that is already in your blood vessel will probably break off at some point and cause another stroke. But we can’t do a surgery to take out the fungus.”
I stopped myself from continuing, allowing the interpreter to do her job, wondering how she translated these concepts effectively. I saw Laura’s expression contort with concern, Noelle’s eyes glaze over. I felt responsible for but unable to handle the growing emotion in the room.
Mr. Tan remained expressionless. He stared at his notepad and wrote out another question.
Can I have laser therapy to kill the fungus? Can you filter the fungus out of my blood?
I could see his engineer’s mind at work, reaching to the farthest corners of possibility for a solution. I shook my head and forced myself to say what I was dreading. I hated the thought of crushing Mr. Tan, of dashing his hopes, but I hated even more the thought of withholding from him what I was just about to say: “It’s just a matter of time before you have another stroke. And it could severely impact your life even more than the other strokes have.”